Provider Demographics
NPI:1043293962
Name:SUNTAY, WILFREDO J (DO)
Entity Type:Individual
Prefix:DR
First Name:WILFREDO
Middle Name:J
Last Name:SUNTAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:L-3402
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43260-0001
Mailing Address - Country:US
Mailing Address - Phone:814-444-1919
Mailing Address - Fax:
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-395-8627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35060771S2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0827430Medicaid
OH4303601Medicare PIN
OH4303603Medicare PIN
OH0827430Medicaid
OH0691139Medicare PIN
E42942Medicare UPIN
OHSU0691134Medicare ID - Type Unspecified